Basic Information
| Provider Information | |||||||||
| NPI: | 1629247861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | SHANTAL | ||||||||
| MiddleName: | ARELIS | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 PINEWOOD PL | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917413640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095447276 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302900 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | ICAN796 | 01 | CA | LA COUNTY DMH | OTHER |